Reserve urged when using therapeutic coma in SE treatment
medwireNews: Therapeutic coma should be reserved for severe refractory convulsive status epilepticus (SE) after adequate and early dosing of first- and second-line drugs in line with current recommendations, say researchers.
They found that therapeutic coma did not significantly affect mortality after accounting for demographics, SE severity, refractoriness and comorbidities, but it did increase length of hospital stay by 60%.
“This appears highly relevant in the context of high daily costs related to management of acutely ill patients and the increased burden of SE”, point out Vincent Alvarez (Hôpital du Valais, Sion, Switzerland) and co-authors in Neurology.
But in a related editorial, Sara Hocker (Mayo Clinic, Rochester, Minnesota, USA) and Bassel Abou-Khalil (Vanderbilt University Medical Center, Nashville, Tennessee, USA) comment that an increase in healthcare costs may make a weak argument against therapeutic coma if “the theory that early seizure control with anesthesia prevents neuronal injury proves to be true.”
They say: “Clinicians should remain committed to early control of generalized convulsive SE via continuous infusion of [intravenous] anesthetic drugs if necessary, in order to protect the brain against excitotoxic cerebral damage. However, it is reasonable to delay initiation of anesthetic drugs in NCSE [non-convulsive SE] for which the risk–benefit analysis is less clear.”
The editorialists agree with Alvarez et al that with excellent adherence to current guidelines and prompt action with initial therapies such as benzodiazepines, “the need for anesthetic drugs may be reduced, reserving them, as the authors advocate, for only the most refractory cases of SE.”
The researchers used a prospective multicentre SE registry to evaluate the effects of therapeutic coma in 362 patients attending tertiary care centres in Massachusetts (Harvard Affiliated Hospitals) and Switzerland (Centre Hospitalier Universitaire Vaudois).
Therapeutic coma was used in 25.4% of patients in Massachusetts and 9.75% of those in Switzerland, despite both groups being similar in terms of SE characteristics and severity.
Alvarez and team suggest that this difference, “despite relatively uniform treatment guidelines”, may result from more systematic use of electroencephalogram in Massachusetts versus Swiss centres, increasing the likelihood of NCSE identification, which was more frequent in the Harvard Affiliated Hospitals, and treatment escalation.
Therapeutic coma was associated with younger age, more comorbidity, greater SE severity, refractory SE and centre, but not mortality; which was associated with increased comorbidity, SE severity, aetiology and refractory SE.
The researchers note that their study lacked the precision to exclude an important effect of therapeutic coma on mortality and did not control for the quality or depth of therapeutic coma, which is highly variable.
And Hocker and Abou-Khalil say examination of the effects of anaesthetic drugs on cognitive outcome is necessary to determine whether this may justify the longer hospital stays and healthcare costs associated with the treatment.
By Lucy Piper
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